Periodontal Staging and Grading SRM

Question 1

Periodontitis: Armitage 1999
*Severity of disease based upon
*Slight: —
*Moderate: —
*Severe: —

Answer 1

Clinical Attachment Level (Gold Standard)

1‐2 mm
3‐4 mm
≥ 5mm

Question 2

So why the change?
*Few practitioners use clinical attachment level (CAL) routinely
*AAP formed a Task Force in 2015 to identify alternative criteria including
(3)

Answer 2

*Radiographic Bone Loss (RBL)
*Probing Depth (PD)
However, a 6 mm probing depth with 20% bone loss is significantly different that 6 mm
with 75% bone loss

Question 3

2015 Task Force vs. 2017 Workshop
*Probing depth not considered diagnostic
(2)

Answer 3

*Inflammation has effect on penetration of probe into tissue
*Inflammation (swelling) may move gingival margin coronally (pseudopocket)

Question 4

*Workshop Recommendations
(2)

Answer 4

*Use Interproximal Attachment Loss (2 or more non‐adjacent teeth)
*Use probing depth as a ‘complexity’ factor (difficulty of treatment)

Question 5

2017 Classification of Periodontal and Peri‐implant
Diseases and Conditions
*New classification based on

Answer 5

strongest current evidence.
*Clarifies ‐Contemporizes
*Adaptive System‐3 dimensional

Question 6

Adaptive System‐3 dimensional
(3)

Answer 6

*Severity/Extent (number of teeth affected rather than sites)
*Prognosis (affects no teeth, up to 4 teeth, 5 or more teeth)
*Progression (Grading)

Question 7

2017 AAP Classification
Rationale for change is to
(2)

Answer 7

*Recognize and monitor systemic influences INFLOWING to Periodontal
Disease such as Smoking and Diabetes
*Control Inflammatory and Microbial influences from Periodontal Disease
OUTFLOWING to systemic targets to decrease the co‐morbid effect of the
periodontal disease

Question 8

NHANES 2009‐2014
*10,683 dentate subjects 30 years or older
*42% periodontitis
*7.8% severe
*34.4% non‐severe
*Prevalence of non‐severe and total increased with age
*Greatest amongst men (50.2%), Mexican Americans (59.7%), adults below 100% of Federal poverty level (60.4%), current smokers (62.4%) and self reported diabetes (59.9%)
*Prevalence of total disease highest in those who did not use dental floss or visit dentist regularly

Answer 8

*Centers for Disease Control and Prevention‐approximately 47% of adults >30 years old have periodontitis and this is the primary cause of tooth loss in adults.
SRM

Question 9

Goal of New System
Staging and Grading
(3)

Answer 9

*Easy to use
*Should promote better communication (?) with
*Identify response to treatment

Question 10

Should promote better communication (?) with
(3)

Answer 10

*Patient
*Referring dentists, hygienists
*Other health care professionals

Question 11

AAP 2017 Classification
Staging and Grading
*Every patient categorized based on the — periodontal site and specific
factors that may impact long term management
*Staging is divided into
(3)

Answer 11

worst

*Severity
*Complexity
*Extent and distribution

Question 12

STAGING
*“Staging” (1‐4) based upon severity of disease and complexity
of case management
Considers:
(6)

Answer 12

*Clinical attachment loss (CAL)‐using worst site
*Amount and % of bone loss
*Probing depth
*Presence/extent of ridge defects and
furcation involvement
*Tooth mobility
*Tooth loss (due to periodontitis if known)

Question 13

Criteria for Defining Periodontitis
*Interdental Clinical Attachment Loss at —
OR
*Buccal or Oral Clinical Attachment Loss —
*with pocketing —
*on — or more teeth

Answer 13

2 or more non‐adjacent teeth

≥ 3 mm
>3mm
2

Question 14

Caution
*Ensure the problem cannot be attributed to non‐periodontal causes such as
(5)

Answer 14

*Gingival recession due to trauma (toothbrush trauma/toothpaste abrasion)
*Dental caries extending to or below the gingival margin
*Defect on distal of 2nd molars caused by malposition or extraction of a 3rd molar
*Endodontic lesion draining through marginal periodontium (deep probing depth)
*Vertical root fracture (usually isolated deep probing depth)

Question 15

Complexity
*Takes into account overall
*Evaluates (2)

Answer 15

probing depths

*Evaluates radiographic bone loss, horizontal and vertical
*Evaluates furcation involvements, number of missing teeth, function

Question 16

Periodontitis: Local
Stage I
(2)

Answer 16

*Max probing
depth ≤ 4 mm
*Mostly
horizontal bone
loss

Question 17

Periodontitis: Local
Stage II
(2)

Answer 17

*Max probing
depth ≤ 5 mm
*Mostly
horizontal
bone loss

Question 18

Periodontitis: Local
Stage III
(3)

Answer 18

In addition to
Stage II
complexity
*Probing
depths ≥ 6mm
*Vertical bone
loss ≥ 3mm
*Class II or III
Furcation
Involvements
*Moderate
ridge defects

Question 19

Periodontitis: Local
Stage IV
(5)

Answer 19

In addition to Stage III
complexity
Need for complex rehabilitation
due to
*Masticatory dysfunction
*Secondary Occlusal Trauma
(≥ 2 mobility)
*Bite collapse, drifting, flaring
*<10 opposing pairs remaining
teeth (<20 teeth total)
*Severe ridge defects

Question 20

Stage I or II
Tooth Loss

Answer 20

No tooth loss likely

Question 21

Stage III
Tooth Loss

Answer 21

Risk of tooth loss (up to 4)

Question 22

Stage IV
Tooth Loss

Answer 22

Risk of loss of arch or dentition (>5
teeth)

Question 23

Prognosis based upon Staging
***Remember tooth loss MUST be due to

Answer 23

Periodontitis

Question 24

Stage 1
*Stage I (initial)
CAL
% BL
Tooth loss
PD
Type of BL

Answer 24

*1–2 mm clinical attachment loss (CAL), less than 15% bone loss (BL) around
root, no tooth loss due to periodontal disease, probing depth (PD) 4 mm or
less, mostly horizontal BL

Question 25

Stage 2
*Stage II (moderate)
CAL
% BL
Tooth loss
PD
Type of BL

Answer 25

3–4 mm CAL, 15%–33% BL, no tooth loss due to periodontal disease, PD 5 mm
or less, mostly horizontal BL

Question 26

Stage 3
*Stage III (severe with potential for additional tooth loss)
CAL
% BL
Tooth loss
PD
Type of BL
Others (2)

Answer 26

5 mm or more CAL, BL beyond 33%, tooth loss of four teeth or less (due to
periodontal disease), with complex issues such as PD 6 mm or more, vertical
BL 3 mm or more, Class II–III furcations, and/or moderate ridge defects

Question 27

Stage 4
*Stage IV (severe with potential for loss of dentition)

Answer 27

Encompasses all of Stage III with additional features that will require the need
for complex rehabilitation due to masticatory dysfunction, secondary occlusal
trauma, severe ridge defects, bite collapse, pathologic migration of teeth, less
than 20 remaining teeth (10 opposing pairs)

Question 28

Tooth Loss due to Periodontitis (if known)
*No tooth loss =
*≤ 4 teeth =
*≥5 teeth =

Answer 28

Stage I or II
Stage III*
Stage IV*

Question 29

*Trump cards

Answer 29

*if lost ANY teeth due to periodontitis, then automatically Stage III or IV

Question 30

Furcation Involvement
Trump card

Answer 30

*Furcation involvement of Grade 2 or 3 automatically puts patient into
Periodontitis Stage 3 or 4 (Severe or Very Severe)

Question 31

EXTENT AND DISTRIBUTION
(Added to Stage as a Descriptor)
Concept is to know percentage of teeth affected by periodontitis of ANY
Stage
*1. Localized—
*2. Generalized—
*3. Molar‐incisor—

Answer 31

Bone Loss involves less than 30% of teeth in mouth
Bone Loss involves more than 30% of teeth in mouth
BL is found around molar (usually first) and anterior
incisors SRM

Question 32

EXTENT AND DISTRIBUTION
(Added to Stage as a Descriptor)
Molar/Incisor pattern generally applies to ‘old’ classifications of
*Localized Aggressive Periodontitis which was known before that as
*Localized Juvenile Periodontitis
Now

Answer 32

Stage III Grade C

Question 33

GRADING
Considers biological features:
(4)

Answer 33

*RATE of disease progression
*Risk for further advancement
*Potential threats to general health (including smoking, diabetes)
*Response to standard therapy

Question 34

GRADING
*“Grading” (A‐C)
*A:
*B:
*C:

Answer 34

Low risk of progression
Moderate risk of progression
High risk of progression

Question 35

Initially assume Grade — then seek specific evidence to shift to Grade

Answer 35

B
A or C

Question 36

1. Direct Evidence
   (2)

Answer 36

*historical radiographic bone loss or
*clinical attachment loss

Question 37

2. Indirect Evidence
   (3)

Answer 37

*% bone loss/patient age
*Case Phenotype (Soft tissue thickness, bone thickness)
*Heavy plaque accumulation but minimal destruction vs. minimal plaque
but major destruction

Question 38

Grading
1. Direct Evidence
(3)

Answer 38

*No loss over 5 years (Grade A)
*< 2mm loss over 5 years (Grade B)
*> 2mm over 5 years (Grade C)
SRM

Question 39

Grading
2. Indirect Evidence
(2)

Answer 39

*% bone loss/age
*Case Phenotype

Question 40

Grading
Modifiers (RISK factors)
Smoking and Diabetes
Grade A: (2)

Answer 40

Slow rate
Nonsmoker, nondiabetic

Question 41

Grading
Modifiers (RISK factors)
Smoking and Diabetes
Grade B: (3)

Answer 41

Moderate rate
< 10 cigarettes/day
Diabetic with HbA1c <7%

Question 42

Grading
Modifiers (RISK factors)
Smoking and Diabetes
Grade C: (3)

Answer 42

Rapid rate
≥ 10 cigarettes/day
Diabetic with HbA1c ≥ 7%

Question 43

*Chronic periodontitis, aggressive periodontitis =

Answer 43

Periodontitis

Question 44

Periodontal biotype =

Answer 44

Periodontal phenotype

Question 45

Excessive occlusal force =

Answer 45

Traumatic occlusal force

Question 46

Biologic width =

Answer 46

Supracrestal Attached Tissue
(Supracrestal Connective Tissue + Junctional Epithelium)